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art science

This page introduces the latest research findings in a brief and accessible form,
and offers you insights into the world of biomechanics and medical technology
(reviews written by Dr. Sophie Elixhauser)

pedar Measurements Show the High Importance of Rapid Leg Force Generation in Diagonal Cross-country Skiing

The diagonal stride is a common uphill technique in cross-country skiing. It is well-known that increasing the velocity in skiing is linked to the cycle rate and cycle length. Based on studies from roller-skiing and on-snow skiing, researchers Andersson et al.  speculated that “an increased cycle rate at a long cycle length is the main factor for increasing a high sub-maximal velocity up to a maximal velocity” (2) in diagonal cross-country skiing on snow. Yet, the exact role of cycle rate, cycle length, and time for force generation at different velocities had not previously been tested for this type of skiing. Andersson et al. therefore examined cycle and force characteristics in 11 male elite cross-country skiers skiing uphill with the diagonal stride technique at three different velocities (moderate, high & maximal). Using novel’s pedar® mobile system, they analysed plantar leg force and pole force, which they combined with video analysis and photocell measurements. They found that cycle length and cycle rate increased from moderate to high velocity, and maximal velocity was attained by elevating cycle length and decreasing cycle rate. The tests further showed that “that the development of leg force was considerably faster during diagonal skiing on snow than for roller-skiing” (17). The researchers therefore conclude that when training roller-skiing athletes should “focus on generating high vertical leg forces early during the kick in order to avoid a technique adaptation that might result in ‘slipping’ when skiing on snow” (17). All in all, these tests show the high importance of rapid leg force generation in fast diagonal skiing.

Andersson, E; Pellegrini, B; Sandbakk, Ø; Stöggl, T and H-C Holmberg (2014):
The effects of skiing velocity on mechanical aspects of diagonal crosscountry skiing.
Sports Biomechanics, DOI: 10.1080/14763141.2014.921236

Pedar Tests about Limb Loading and Stability during Squatting after Total Hip Arthroplasty

Squatting is a movement frequently carried out during many daily tasks. Due to its demands on knee and hip musculature, squatting remains a common goal in many rehabilitation programmes. Scientific studies have inquired into the effect of knee osteoarthritis and total knee arthroplasty on squatting, finding asymmetrical loading between affected and non-affected limbs or slow and unbalanced movement execution. The hip, nevertheless, has not been examined in this respect. Researchers Brauner et al. therefore decided to study the effects of unilateral total hip arthroplasty (THA) on people’s squatting abilities, particularly during early functional recovery of patients.

They examined 61 test subjects (34 men, 27 female) who had undergone THA, and the results were later compared to a healthy reference group. Before the trial, each person was asked to complete the Function Assessment Questionnaire Hannover for Osteoarthritis. By means of 2 pedar® posturo pressure mats, the researchers tested the interlimb vertical force distribution and the dynamic stability during the squat manoeuvre. Similar to the aforementioned studies about the knee, they found that “patients who had undergone THA perform squats with an unloading of the operated limb and reduced dynamic stability”. Yet though limb loading became more symmetric and stability improved with rehabilitation, anteroposterior stability remained impaired. These results provide quantitative information that can be used to monitor the clinical progression and early functional recovery of patients with THA.

Brauner, T; Wearing, S; Rämisch, E; Zillober, M; and T Horstmann (2014):
Can measures of limb loading and dynamic stability during the squat maneuver provide an index of early functional recovery after unilateral total hip arthroplasty?
Archives of Physical Medicine and Rehabilitation 95(10): 1946-1953

emed Tests show an Improvement of Plantar Pressures after ATTT Clubfoot Surgery in Children

While treatment of children born with clubfoot nowadays often follows well-described non-operative approaches, relapse is not uncommon following initial correction. In children older than 2.5 years, a recommended surgical approach is to transfer the anterior tibialis tendon (ATTT) laterally to the third cuneiform, third/fourth metatarsal or to the cuboid. The use of pedography has become quite common to test plantar pressures in children with clubfoot. However limited work has been done to assess functional outcome following ATTT.

Using novel’s emed® technology, the group of researchers around Kelly Jeans from Dallas, Texas, embarked on a study to objectively test whether plantar pressures normalize after ATTT. Between 2003 and 2010, thirty children with clubfoot (37 clubfeet) underwent gait analysis and plantar pressure tests, which implied walking on the emed® platform for a minimum of five trials for each foot both preoperatively and postoperatively, i.e. one to two years after the surgery. Contact area, contact time, and peak pressures were quantified for seven different regions of the foot. The researchers found significant differences between preoperative and postoperative outcomes. The changes after ATTT, as they conclude, show that “the foot is better aligned for a more even distribution of pressure throughout the foot, but is not fully normalized”.

Jeans, K; Tulchin-Francis, K.; Crawford, L. and L.A. Karol 2014:
Plantar pressures following anterior tibialis tendon transfers in children with clubfoot.
Journal of Pediatric Orthopaedics
34 (5): 552-558

novel pedar trial about the effects of strengthening, stretching and functional training on foot function in patients with diabetic polyneuropathy

Patients with diabetic polyneuropathy (DPN) are more likely to develop planter ulceration due to alterations in the foot rollover process during walking and an overall worsening of foot-ankle muscular, articular and nervous function.  The Brazilian/Italian group of researchers around Cristina Sartor and Isabel Sacco have tested the effects of strengthening, stretching and functional training on foot function in patients with DPN. The study was based on the hypothesis that these interventions could lead to the recovery of muscles and joint functions and help DPN patients “to maintain, for as long as possible, the residual capability to interact safely with the ground while walking or standing.”

Sartor et al. recruited 55 patients with DPN between 45-65 years of age. The intervention group of 26 persons underwent administered foot-ankle and gait training twice a week for an overall period of 12 weeks, whilst the control group of 29 persons received standard medical care. Plantar loading distribution was measured using novel’s pedar® system and the collected data were analysed with the software novel-projects. In comparison to the control group, the researchers found that the intervention “discreetly changed foot rollover towards a more physiological process, supported by improved plantar pressure distribution and better functional condition of the foot ankle complex.“ They therefore recommend these exercises as a complementary intervention to patients with DPN to be repeated periodically.

Sartor, CD; Hasue, RH; Cacciari, LP; Butugan, MK; Watari, R; Pássaro, AC; Giacomozzi, C; Sacco, ICN (2014):
Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial.
BMC Musculoskeletal Disorders 15:137 doi:10.1186/1471-2474-15-137

The Effects of Foot Orthoses on Lower Limb Muscle Activity and Plantar Pressure (novel pedar measurement)

Customised foot orthoses (FOs) featuring extrinsic rearfoot posting are widely used for the treatment of symptomatic pronated foot type. Various FOs exist differing mainly with regard to their customisation to the individual patient. Previous research using surface electromyography (EMG) has found that FOs can affect muscle activity during gait. Likewise, plantar pressure distribution may be altered by the use and dose of FOs. But the specific dose response effect on these parameters has not yet been quantified.

The group of researchers Telfer et al. thus decided to test the dose response effect of customised FOs on EMG activity of selected lower limb muscles and on the distribution of in-shoe plantar pressure, and the effect of foot types on these variables. They measured EMG and plantar pressure effects of varying the dose in two groups of participants, with normal and pronated foot types respectively. novel’s pedar® system was used for the in-shoe plantar pressure measurements. The outcomes of this study lead Telfer et al. to conclude that “there is a significant and linear dose response effect of FOs on plantar pressure variables at the rearfoot, midfoot and forefoot” (p. 6).  No such effect could be found for muscle activity.  Moreover, foot type appeared to play an important role in the effect of FOs on above-knee muscle activity.
Telfer, S; Abbott, M.; Steultjens, M.; Rafferty, D.; and J.Woodburn (2013)
Dose-response effects of customised foot orthoses on lower limb muscle activity and plantar pressures in pronated foot type.
Gait & Posture 38(3): 443-449

novel pedar Performing Well in a Study on the Validity and Repeatability of Three In-shoe Pressure Measure Systems

In-shoe pressure measurement systems are used to quantify pressure on the plantar foot. Various different in-shoe pressure measurement systems – including novel’s pedar® technology – are available for test situations in clinical and research settings. As practice shows, they differ in validity and repeatability. The scientists Price, Parker and Nester embarked on a study to analyse three in-shoe pressure measurement systems: Medilogic, Tekscan and pedar®. Using a calibration device, measurements were undertaken in a 2 day x 3 repeated trial design across a range of applied pressure magnitude and durations.

The results of pedar® were particularly good. The researcher found that “Medilogic and Tekscan are most effective between 200-300 kPa” whereas “pedar® performed well across all pressures”. They therefore concluded that “The choice of an appropriate pressure measurement device must be based on the duration of loading, magnitude of loading and the outcome variables sought“.

Price, C; D Parker; CJ Nester 2014:
Validity and repeatability of three commercially available in-shoe pressure measurement systems.

Journal of Foot and Ankle Research 7 (Suppl 1): A67,
From: 4th Congress of the International Foot and Ankle Biomechanics (i-FAB) Community
Busan, Korea. 8-11 April 2014

novel emed Measurements on the Effect of Gait Speed Changes on Foot Loading in Children

While much research has been devoted to the influence of gait speed in foot loading in adults, its effects on the foot loading characteristics in children in the stages of general growth and development have not yet been evaluated. Scientists Rosenbaum, Westhues and Boesch therefore embarked on a study to test twenty typically developing children between four and twelve years of age. The subjects were asked to walk across a novel emed® platform at normal, slow and fast walking speeds, with five repeated trials for each walking speed. The data were stored and analysed in a novel data base programme.

The results of the study showed that in the fast walking speed conditions - in spite of shorter contact times - foot loading significantly increased in the hindfoot, medial and central forefoot and toes while it slightly decreased in the lateral midfoot and forefoot. The authors conclude that the results of this research “generally confirm the findings in adults that gait speed does not uniformly affect foot loading characteristics and that these effects should be kept in mind when comparing different subject groups or children at repeated measurement occasions.” (1058)

Rosenbaum, D., Westhues, M. and K. Bosch (2013)
Effect of gait speed changes on foot loading characteristics in children.
Gait & Posture 38 (4): 1058-60

The Struggle against Pressure Ulcers: Contact Pressure in Bed Measured with novel pliance Technology

Pressure (or decubitus) ulcers are a regular occurrence in critically ill patients in intensive care units. To prevent and treat pressure ulcers, patients are regularly placed in different positions in bed and segmented beds are used that can be moved in different positions. Yet the optimum position of a patient in bed is still controversial. Studies have further found that the type of mattress has a significant influence on the development of pressure ulcers.

Korean researchers Bae and Ko therefore investigated the effects of changes in bed position on different types of mattresses on the contact pressure between the patient’s body and the mattress. By means of novel’s pliance® system, they tested 15 healthy subjects (differentiated into three groups: normal, overweight, and underweight). They set up five positions of three-stage segmental motorized beds and used four types of ulcer-preventing mattresses (latex, bubble, alternative, and air types) and an ordinary hospital mattress.

With regard to the subject’s position in bed, the head-foot at 30° degrees position in the segmental bed was found to be the best position to alleviate the development of pressure ulcers. The air mattress was found to be the best respective mattress. The study further showed that underweight patients are the group most vulnerable to pressure ulcers. Researchers Bae and Ko therefore stressed the importance of considering the characteristics of the patients (e.g. the body mass index), in addition to patients’ positioning in bed and the type of mattress, in research and development of ulcer-preventing mattresses.

Bae, T.S. and C.W. Ko (2014):
Biomechanical effect of changes in bed positions and different types of mattresses in preventing decubitus ulcer.
Tissue Engineering and Regenerative Medicine 11 (1): 93-98

Treating metatarsal stress fractures with a rigid carbon graphite footplate inside the sporting shoe

Stress fractures in the fifth metatarsal bone frequently affect athletes across various sports, and the healing process often entails complications such as delayed or non-union of the metatarsal bone. Standards of care have included the use of a rigid carbon graphite footplate inside the sporting shoe, along with custom orthotics and foot braces.

The group of U.S. American researchers Queen et al. have tested the effects of a rigid carbon graphite footplate on the plantar loading during take-off and landing from a jump. Their study was based on the hypothesis that such a footplate is able to decrease plantar loading beneath the lateral aspect of the foot. By means of a novel pedar® in-shoe pressure measurement system, the researchers assessed 19 recreational male athletes who completed seven jumping tasks wearing two different kinds of sporting shoes with and without a rigid carbon graphite footplate.

This study did not confirm the initial hypothesis. It showed that a rigid carbon graphite footplate does not reduce plantar loading during jumping. The researchers therefore underline “the need to explore other treatment modalities for 5th metatarsal stress fractures that could improve fracture healing, reduce the occurrence of re-injury, and accelerate return to play for athletes.” (p. 710)

Queen, R.M..; Verma, R.;  Abbey, A.N.; Nunley, J.A.; and R. J. Butler (2014):
Plantar loading during jumping while wearing a rigid carbon graphite footplate
Gait & Posture 39: 707–711

Research on the Relations between Foot Structure and Foot Function

Many foot pathologies are typical for specific foot types. Since each foot type is characterized by particular foot structures, researchers Mootanah et al. embarked on a study to test whether foot structures are also related to specific foot functions. Evidence of this hypothesis could help with differential diagnosis of foot pathologies.

The team of researchers tested 61 healthy subjects featuring three different foot types (cavus, rectus, planus). Plantar loading parameters were assessed with a novel emed® measurement platform, and several measures of foot structures, anthropometrics (height and weight), age, and walking speed were related to biomechanical measures of foot function. Mootanah et al. were able to confirm their hypothesis that foot structure and anthropometrics are related to foot function. These findings are basic measurements that could be used in a clinical setting.

Mootanah, R., Song, J., Lenhoff, M.W., Hafer, J.F., Backus, S.I., Gagnon, D., Deland J.T., and H.J. Hillstrom (2013)
Foot Type Biomechanics Part 2: Are structure and anthropometrics related to function?
Gait & Posture 37: 452–456

Back Pain among Alpine Ski Racers Tested with novel pedar Technology

Recurrent and chronic back pain is a common occurrence in many ski athletes. Biomechanical research has shown that in the loaded and bended spine the similar occurrence of torsion increases spinal disc loading. It did not confirm, however, whether these loading characteristics also apply to ski racing athletes. Spörri et al. therefore conducted a study on the overall trunk motion of six European Cup level athletes. The variables of different bending and torsion angles were calculated and analysed; novel pedar® technology was used for measuring the total ground reaction forces.  
This study confirmed the initial hypothesis that the aforementioned trunk loading characteristics most likely lead to the high prevalence of back problems among alpine ski racers. Spörri et al recommend that “potential prevention strategies should primarily aim on controlling or reducing the magnitude of those movements“.

Spörri, J., C. Haid, J. Kröll, B. Fasel and E. Müller (2013)
Trunk load characteristics in Alpine ski racing.
6th International Congress on Science and Skiing - Book of Abstracts.

New Findings Resulting from novel pedar Measurements on the Effect of Ankle Position in a Short Leg Walking Boot

For the treatment of diabetic foot ulcers, short leg walking boots have proven to be an effective alternative healing method to total contact casts. It is well known that alterations in ankle position in these methods affect plantar pressure distribution and ultimately the healing process. Up to now, it was assumed that “placing the ankle in slight dorsiflexion optimizes unloading of the forefoot and, conversely, that plantarflexion of the ankle increases pressures under the forefoot” (70). Preliminary findings of U.S. American researchers Crenshaw et al., however, suggested the exact opposite, namely that placing the ankle in slight dorsiflexion increases forefoot pressures.

Crenshaw and her team therefore embarked on a study about the phenomenon of ankle position on plantar pressure distribution in a walking boot. With novel’s pedar® system, they measured plantar pressure in thirteen healthy subjects (5 female, 8 male), thereby comparing three different conditions of ankle angle. This study confirmed their initial hypothesis that, contra to former assumptions, “dorsiflexing the ankle slightly may help with the healing of hindfoot ulcers, while plantarflexing the ankle slightly may help with the healing of forefoot ulcers” (71).

Crenshaw, S.J., Pollo, F.E., and J.W. Brodsky (2004):
The Effect of Ankle Position on Plantar Pressure in a Short Leg Walking Boot.
Foot & Ankle International 25 (2): 69-72

novel emed and pedar: Research on the relation of foot ulceration, plantar pressure and daily cumulative stress in persons affected by leprosy

Both plantar pressure and weight-bearing activity affect accumulated mechanical stress to the foot and may stand in relation to foot ulceration. Persons affected by leprosy often suffer from the effects of foot ulceration. Nevertheless, only limited research has been available on the relation between foot ulceration, plantar pressure and daily cumulative stress in leprosy patients. The scientists van Schie et al. from the Academic Medical Centre in Amsterdam therefore conducted a study "to compare barefoot peak pressure of the foot, in-shoe peak pressure of the foot and daily cumulative stress between persons affected with leprosy with a current, a previous and without a previous plantar foot ulcer" (p. 327). The aim was to find out which parameter is most strongly related to current foot ulceration.

Using novel emed® and pedar® technology, tests were carried out with nine subjects with current plantar ulceration and compared to 15 persons with previous and 15 persons without previous ulceration. Persons with current and previous foot ulceration showed increased barefoot peak pressure, whilst in-shoe peak pressure was only increased in persons with current foot ulceration. Daily accumulative stress showed no difference between the groups, although persons with current or previous ulceration were less active. Van Schie et al. conclude that "Increased in-shoe peak pressure may suggest insufficient pressure reducing footwear in persons with current foot ulceration and highlights the importance of paying attention to pressure reducing properties of footwear, which may reduce the risk of foot ulcer development" (p. 229). Further research is needed on the pressure reduction qualities of footwear for leprosy patients.

Schie van, C.H.M., Slim, F.J., Keukenkamp, R., Faber, W.R., Nollet, F. 2013:
Plantar pressure and daily cumulative stress in persons affected by leprosy with current, previous and no previous foot ulceration.

Gait & Posture 37: 326–330

By means of novel’s pedar system, researchers developed a new test protocol for footwear prescriptions for the Diabetic foot

Aiming at improving the foot care of Diabetic neuropathic patients, researchers Giacomozzi and Uccioli have developed a standardised and objective test protocol for measuring the performance of footwear prescriptions for the Diabetic foot. Whilst several studies in this field had been published already, a reliable test protocol based on a few parameters and proper threshold values was still missing.

Using novel’s pedar insole system, reference data was collected from 20 healthy volunteers at an outpatient service for the Diabetic foot. The volunteers best resembled the expected Diabetic patients as for age, BMI, and long stance phase. The test protocol developed is based on four major foot regions and two main indicators - reference peak pressure thresholds and gait line specific for different levels of risk. A preliminary validation session of the protocol was proved successful and it was well received with patients and operators.

Giacomozzi, C. and L. Uccioli (2013):
Learning from experience: A simple effective protocol to test footwear prescriptions for the Diabetic foot by using the Pedar system.
Journal of Biomedical Science and Engineering 6: 45-57

Research carried out by Isabel Sacco, Associate Professor (University of São Paulo, Brazil) by means of novel technology

We would like to draw your attention to the valuable research carried out by Isabel Sacco, PhD, Associate Professor at the Department of Physical Therapy, Speech and Occupational Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil.

Researching into sports, diabetes and feet, and in particular running and shoe construction technology, Professor Sacco has worked with novel pedar technology for many years.
In addition to her research and academic teaching as an associate professor at the University of São Paulo, Professor Sacco works as a scientific consultant for novel GmbH.

Please take into account Isabel Sacco’s latest research articles:

Tessutti V, Ribeiro AP, Trombini-Souza F, Sacco IC.
Attenuation of foot pressure during running on four different surfaces: asphalt, concrete, rubber, and natural grass.
Journal of Sports Sciences
Aliberti S, Costa Mde S, Passaro Ade C, Arnone AC, Hirata R, Sacco IC.
Influence of patellofemoral pain syndrome on plantar pressure in the foot rollover process during gait.
Clinics (Sao Paulo) 2011;66(3):367-72
Ribeiro AP, Trombini-Souza F, Tessutti VD, Lima FR, João SM, Sacco IC.
The effects of plantar fasciitis and pain on plantar pressure distribution of recreational runners.
Clinical Biomechanics (Bristol, Avon)
Aliberti S, Costa MS, Passaro AC, Arnone AC, Sacco IC.
Medial contact and smaller plantar loads characterize individuals with Patellofemoral Pain Syndrome during stair descent.

Physical Therapy in Sport

Sacco IC, Bacarin TA, Canettieri MG, Hennig EM.
Plantar pressures during shod gait in diabetic neuropathic patients with and without a history of plantar ulceration.

Journal of the American Podiatric Medical Association

Sacco IC, Hamamoto AN, Gomes AA, Onodera AN, Hirata RP, Hennig EM.
Role of ankle mobility in foot rollover during gait in individuals with diabetic neuropathy.
Clinical Biomechanics (Bristol, Avon) 2009;24(8):687-92
Bacarin TA, Sacco IC, Hennig EM.
Plantar pressure distribution patterns during gait in diabetic neuropathy patients with a history of foot ulcers.

Clinics (Sao Paulo)

Tessutti V, Trombini-Souza F, Ribeiro AP, Nunes AL, Sacco Ide C.
In-shoe plantar pressure distribution during running on natural grass and asphalt in recreational runners.
Journal of Science and Medicine in Sport 2010;13(1):151-5

Diploma Thesis on the Gripping Forces During the Golf Swing - Supervised by Dr Axel Kalpen, CTO novel GmbH

For his diploma thesis, Ender Türk, a graduate in mechatronics and precision engineering from the University of Applied Sciences Munich, conducted research on the temporal coordination of the gripping forces during the golf swing. The study was carried out at novel’s biolab, and was supervised by novel CTO Dr Axel Kalpen.

With novel’s pliance system, Türk measured the dynamic load distribution during the golf swing, and developed a new system that is able to visualise the gripping forces in their temporal sequence. This method may demonstrate mistakes in golf swing through incorrect grip position right during a training session. It provides a valuable instrument for golf teachers and golfers to improve gripping habits for a better golf performance.

Türk, Ender (2007): Zeitliche Koordination der Griffkräfte beim Golfabschlag.
Diploma Thesis, Department of Applied Sciences and Mechatronics, University of Applied Sciences Munich.

Single Leg Balancing in Ballet Tested with novel’s emed Platform

Ballet dancers are known for their ability to perform impressive balanced poses. During most single leg ballet poses, the gesturing leg performs the step, while the supporting foot responsible for the weight bearing rests in a demi-pointe position (90° extension of the big toe joint).

Enquiring into the effects of different shoe conditions and poses on stability levels, researchers Lobo da Costa et al. have used a novel emed platform to test selected single leg ballet poses performed in a demi-pointe position. In two experimental conditions, with slippers and barefoot, fourteen experienced, non-professional, healthy, female ballet dancers aged between 15 and 25 years performed the poses attitude devant, attitude derriére, and attitude a la second. A comparison of the respective peak pressures, contact areas, centre of pressure (COP) oscillation areas, anterior-posterior and medio-lateral COP oscillations and velocities showed that barefoot performances produced more stable poses and that the stability among the ballet poses was only different when tested barefoot. The study further indicated that attitude a la second is the least challenging and attitude derriére the most challenging pose.

Lobo da Costa, P.H., F.G.S. Azevedo Nora, M. Fraga Vieira, K. Bosch, and D. Rosenbaum (2013):
Single Leg Balancing in Ballet: Effects of Shoe Conditions and Poses
Gait & Posture 37: 419–423

Chinese Researchers Analyse Pressure Therapy on Hypertrophic Scars with pliance-x

Pressure therapy has been a method for scar management since the 1970s. While pressure therapy was reported as successful in many cases, the treatment of excessive scars showed only insignificant improvements. One of the reasons for these inconsistencies might be the failure to document the accurate pressure magnitude, Chinese researchers Candy et al. have argued.

With the help of novel’s pliance-x system, Candy et al. tested the effect of different pressure magnitudes on 53 hypertrophic scar samples from 17 Chinese participants. Comparing the therapeutic outcomes of hypertrophic scars under low (10–15 mmHg) and high (20–25 mmHg) pressures, they found that both pressure groups produced a reduction in scar thickness and redness. The higher pressures, however, were more effective in comparison to the lower pressures, though higher pressures at the same time were more prone to pressure loss.

Candy LHY, Li-Tsang, C, Zheng, YP (in press). Effect of different pressure magnitudes on hypertrophic scar in a Chinese population.
Burns (2010), doi:10.1016/j.burns.2010.05.008.

Changing Foot Loading Patterns by Walking With In-toeing or Out-toeing Gait Modifications

Inborn in-toeing or out-toeing gait patterns in children feature prominently as a reason for parents to seek pediatric-orthopedic advice.  These gait patterns can also be observed in pathological conditions. Besides the potential harmful effects, in- or out-toeing gait will change the foot progression angle (FPA), which indicates the orientation of the foot during gait, and may therefore affect foot loading characteristics. Rosenbaum investigated whether foot loading patterns may be deliberately changed by either in-toeing or out-toeing gait during barefoot walking.

By means of novel technology, he investigated the gait of 12 normal healthy adults (6 male, 6 female). Five trials of barefoot walking from each foot were conducted, during normal, in-toed and out-toed walking across a capacitive pressure-sensitive platform (emed-x, novel).
The results support the clinical observations that out- and in-toeing gait leads to characteristically altered foot loading patterns. They point out the potential benefits of consciously altering the gait pattern in order to off-load certain plantar regions.

Rosenbaum D. (2013): Foot loading patterns can be changed by deliberately walking with in-toeing or out-toeing gait modifications.
Gait Posture,

Plantar Pressure Difference in Hemiplegic Patients: Decision Criteria for Insole Feedback in Motor Relearning

Motor relearning trainings in hemiplegic patients are based on the attempt to make the plantar pressure on the hemiplegic side to be similar to the normal side. Professional feedback in these trainings is important, and the novel pedar-x system was found to be particularly suitable in this regard. By means of pedar-x, the researchers Sanghan et al have analysed the plantar pressure in hemiplegic patients (8 subjects) and in normal people (24 subjects) to identify the decision criteria of insole feedback in motor relearning. The plantar pressure difference was calculated from the maximum pressure picture and the mean value pressure .

The researchers found a vast difference in the ground reaction force between the hemiplegic side and the normal side during walking in stroke patients as compared to normal persons.  They suggest using the plantar pressure difference from the mean value pressure as the decision criteria for the insole feedback, as this value is clearly distinguished between groups and is easy to obtain.

Sanghan, S., Chatpun S., and W. Leelasamran (2012): Plantar Pressure Difference: Decision Criteria of Motor Relearning Feedback Insole for Hemiplegic Patients.
International Proceedings of  Chemical, Biological and Environmental Engineering 29:29-33

novel pedar System Used to Analyse Tai Chi One-leg Stance

Mao et al. have used the novel pedar-x insole system to analyse the duration and pressure distribution during the one-leg stance in Tai Chi exercise compared to those of normal walking. The aim of the study, carried out on 16 long-term Tai Chi practitioners (8 female, 8 male) during the execution of a set of 42-form, was to elaborate the beneficial effects of Tai Chi on the ability to balance on one leg.

The study showed that in Tai Chi exercise the total duration spent in the one-leg stance is less, whereas the duration of each one-leg stance is longer. The medial–lateral displacement of the centre of pressure is greater in Tai Chi exercise than during normal walking. Likewise, the peak plantar load is located under the first metatarsal head and the great toe in Tai Chi, whereas it is located under the second and third, and fourth and fifth metatarsal heads during walking.

The reseach findings suggest that standing in the one-leg stance for a longer duration during Tai Chi exercise not only increases muscle contraction time and thus enhances muscle strength and endurance „but also improves the somatosensory input in the great toe region to assist in balance control to a greater extent than would be achieved with normal walking“ (644). This may help to manage various activities encountered during daily life and reduce the risk of falls and injuries in elderly persons.

D.W. Mao, D.W., J.X. Li, and Y. Hong (2006): The Duration and Plantar Pressure Distribution During One-leg Stance in Tai Chi Exercise.
Clinical Biomechanics 21 (2006) 640–645

Barefoot Regional Plantar Loading Found to be Related to Midfoot Osteoarthritis

The team of researchers Rao et al. from NY, United States, have confirmed the theory  that regional mechanical stress on the foot is related to symptoms in patients with midfoot osteoarthritis (OA). By the help of novel’s emed technology, they examined barefoot regional plantar loading and self-reported foot pain in 30 patients with midfoot OA, which they compared to 20 asymptomatic, matched control subjects.

The study demonstrates that patients with midfoot OA sustain increased magnitude and duration of regional plantar loading during walking compared to the control subjects. Rao et al. recommend that future studies should assess whether interventions designed to reduce plantar loading might relieve foot pain and/or prevent progression of symptoms in patients with midfoot OA.

S. Rao, J.F. Baumhauer, and D.A. Nawoczenski (2011): Is Barefoot Regional
Plantar Loading Related to Self-Reported Foot Pain in Patients with Midfoot Osteoarthritis

Osteoarthritis and Cartilage 19: 1019-1025

Important Research Done by Prof Abboud (University of Dundee, UK) by Means of novel Technology

We would like to draw your attention to the valuable work of Professor Rami J Abboud, Head of the Department of Orthopaedic and Trauma Surgery and Director of the Institute of Motion Analysis and Research. University of Dundee, Scotland, UK.

Since the 1980s, Prof Abboud carried out numerous research projects in biomechanics and motion analysis. His research focuses on important aspects of daily activities in relation to posture, movement and ergonomics, with emphasis placed on sports and disability.

Prof Abboud uses novel's latest technology in his research, and he is in close contact with the novel management team.

His newest publications include the following:

“Assessment of Talipes Equinovarus Treated by Ponseti Technique: Three-year Preliminary Report”. The Foot (2012), 22: 90 - 94. L Z Yapp, G P Arnold, S Nasir, W Wang, J G B Maclean, R J Abboud
 “Harmful Cleat of Football Boots: A Biomechanical Evaluation”. Foot and Ankle Surgery (2011), 17: 140 - 144. J Bentley, A K Ramanathan, G P Arnold, W Wang, R J Abboud
“Differences in Foot Pressures between Caucasians and Indians”. Foot and Ankle Surgery (2010), 16: 195 - 198. A Putti, G P Arnold, R J Abboud
“Normal Pressure Values and Repeatability of the Emed-ST2 System”. Gait & Posture (2010), 32: 392 - 394. M Maetzler, T Bochdansky, R J Abboud
“Repeatability of the Pedar-X In-Shoe Pressure System”. Foot and Ankle Surgery (2010), 16: 70 - 73. A K Ramanathan, P Kiran, G P Arnold, W Wang, R J Abboud
“Foot Pressure Differences in Men and Women”. Foot and Ankle Surgery (2010), 16: 21 - 24. A Putti, G P Arnold, R J Abboud                                             
“The Effects of Off-the-Shelf In-shoe Heel Inserts on Forefoot Plantar Pressure”. Gait & Posture (2008), 28: 533 - 537. A K Ramanathan, M C John, G P Arnold, L Cochrane, R J Abboud
“Off-the-shelf In-shoe Heel Inserts - Does Cost Matter?”. British Journal of Sports Medicine (2008), 42: 750 - 752. A K Ramanathan, M C John, G P Arnold, L A Cochrane, R J Abboud
“Do You Get Value for Money When You Buy an Expensive Pair of Running Shoes?” British J Sports Medicine (2008), 42: 189 - 193. R Clinghan, G P Arnold, T S Drew, L Cochrane, R J Abboud                                       
“Normal Pressure Values and the Repeatability of the Emed System”. Gait & Posture (2008), 27(3): 501-505. A Putti, G P Arnold, L Cochrane, R J Abbou
“The Pedar Inshoe Pressure System: Repeatability and Normal Pressure Values”. Gait and Posture (2007), 25: 401 - 405. A B Putti, G P Arnold, L Cochrane, R J Abboud

Diabetes Care in Oman: Obstacles and Solutions

Similar to many Arab countries, the Oman has been facing a dramatic increase in the prevalence in diabetes. This increase in diabetes can be seen as a consequence of the oil business and industrial boom, which led to a sedentary lifestyle characterized by a lack of exercise. Additional factors are bad eating habits and the popularity of junk food among the Omani population, as researcher Ayuraabi from Sultan Qaboos University Hospital (Muscat, Oman) explains. Diabetes control and care, however, leave much scope for improvement. In his analysis of obstacles and solutions in diabetes care in Oman, Alyuraabi calls for an improvement of the organisation of the health care system, additional financial resources to diabetes care, and the development of programmes in order to attract qualified medical professionals (e.g. from abroad). He stresses the importance of the adoption of internationally accepted treatment protocols as well as the availability of new types of diabetes medication in Oman, and the multidisciplinary approach needed for effective diabetes care. Also Omani patients need to increase their responsibility in following the medical and the dietary advice more strictly and increasing the amount of physical activity.

Promising approaches in facing these problems include the active Oman Diabetes Association, and the newly-established National Diabetes and Endocrine Centre in Bausher, the latter which relies on novel pedography technology. The Diabetes Centre has been launched last week by Princess Camilla, Duchess of Cornwall, in the presence of our CTO Dr Axel Kalpen. For a report on the opening of the centre, please see our newest News Flash post.

Alyaarubi, S. (2011): Diabetes Care in Oman: Obstacles and Solutions.
Sultan Qaboos University Medical Journal 11 (3): 343-348

novel pliance System Considered a High-Value Method to Measure Grip Force!

In order to validate novel‘s new method to measure grip force by pressure sensors, Mühldorfer-Fodor and her team compared grip force measurement with the digital dynamometer as gold standard to a special setting with pliance sensor mats. 72 probands performed grip force tests with a pliance system and a digital Jamar dynamometer. For the pliance system, three cyclinders of 10, 20, and 30 cm circumferences were used, which corresponded to the Jamar handle size 2, 3, and 4.
The mean force and maximum force for both methods were measured. The correlation coefficient calculated was 0.9 for all values of the middle and large pliance cylinder in comparison to the Jamar handle size 3 and 4. For the small cylinder/Jamar handle size 2 the correlation coefficient was 0.8. The researchers conclude that the novel pliance system can be considered a value method to measure grip force. It is able to provide a dynamic, high resolution map of the pressure distribution of the fingers, thumb and palm during cylinder grip.

Mühldorfer-Fodor M., Ziegler S., Harms C., Kundt G., Mittlmeier T., and K.J. Prommersberger (2011):
Measurement of Grip Force with a New Sensor Mat
Paper presented at  Eurohand 2011, Combined XVIth FESSH Congress and Xth EFSHT Congress Oslo, Norway, 26-28 May 2011

Theory on the Correlation between Metartarsalgia and Increased Metatarsal Length has been Refuted

In order to test a commonly noted theorysuggesting that metatarsaligia is connected to increased metatarsal length, Kaipel, Krapf and Wyss havecompared two groups of people  – one group with metatarsalgia (46 patients) and one group of symptom-free patients  (45 patients). Using radiography and novel’s dynamic pedobarography, they examined whether metatarsal length correlated with plantar-loading parameters under the corresponding (i.e. first, second, and third) metatarsal heads. Comparing maximal peak pressure and maximal force in patients of the two groups, they did not find any correlation between metatarsal length and plantar-loading parameters. They therefore conclude that the shortening of a symptomatic ray to decrease plantar-loading parameters cannot be supported from a biomechanical rationale.

Kaipel, M.; Krapf D., and C. Wyss (2011):
Metatarsal Length does not Correlate with Maximal Peak Pressure and Maximal Force.
Clinical Orthopaedics and Related Research 469 (4): 1161-1166

Pressure Distribution on the Hand whilst Gripping Cylindrical Objects

The research team Mühldorfer-Fodor et al., including the Head of our Biomechanic Lab Dr Axel Kalpen, has conducted a study on the load distribution patterns of the hand when gripping cylindirical objects. Seventy-six probands (18-65 yrs old) performed grip force tests for three cylinders of 10-, 20-, and 30-cm circumferences. Using the novel pliance manugraphy system, the loading pattern within the fingers, thumb and palm was analyzed. The study results indicate that the load bearing function of the thumb is higher in the larger cyclinders than in the middle ones, for instance, whereas the little finger takes the highest proportion of gripping when gripping the small cylinders. The middle and ring fingers take an important portion of the load in any cylinder size.

Mühldorfer-Fodor M., Ziegler S., Harms C., Cristalli, A., Kalpen A., Kundt G.,
Mittlmeier T., Prommersberger K.J. (2012):
A-0348 Pressure distribution within the hand during cylinder grip (FESSH Abstracts).
The Journal of Hand Surgery (Eur) 37 (Supplement 1): S69-S70

Thanks to novel pedar and pliance Technology, Researchers Found a New Method to Measure the Load Transfer in Total Contact Casting (TCC)

Using novel pedar and pliance technology, Begg et al have conducted a study on the feasibility to directly measure the load transfer from the plantar surface of the foot to the walls of a total contact cast. Total contact casting (TCC) is considered the ‘gold standard‘ for the treatment of plantar foot ulcers in people with diabetes. Up to now, the load transfer to the cast wall has been measured only indirectly. This proof of concept study aimed to find a new way to directly measure the load transfer using capacitance sensors. This method based on novel pedar and pliance technology showed very similar results to previous indirect assessments and, as Begg et al concluded, offers a more comprehensive understanding of the mechanism of load transfer from the plantar surface of the foot to the cast walls of the total contact cast.

Begg, L., McLaughlin, P., Manning L., Vicaretti, M., Fletcher J. and J. Burns (2012).
A novel approach to mapping load transfer from the plantar surface of the foot to the walls of the total contact cast: a proof of concept study.
Journal of Foot and Ankle Research 2012, 5:32

pliance Tests Give Birth to a Remarkable New Saddle Girth Used by the Olympic Team

Fairfax Saddles have developed a remarkable new saddle girth that substantially improves the horse’s range of movement and reduces the asymmetry within the horse’s movements. The girth’s development builds upon tests with novel’s pliance pressure measuring system which showed – rather surprisingly – that the peak pressure under a girth rests behind the point of the elbow and not on the sternum, as previously assumed. The new girth puts up to 85% less pressure at the key spots where conventional girths accumulate pressure. After the new girth was successfully tested by the British Equestrian Federation (BEF) in the beginning of 2012, it was kept a secret for several months to give the British Olympic team an edge.

Bell, J (2012): The girth Team GBA kept as a secret weapon.
Horse & Hound
30 August 2012, 58-60

The Effects of Speed and Incline on Plantar Pressure during Treadmill Jogging

Ho et al. have analysed the effects of changes in speed and incline on plantar pressure during treadmill jogging. Plantar pressure distribution was measured with the novel pedar-X system in 20 young women with an average age of 20.7. The Taiwanese researchers found that with the increase of speed, apart from the hallux and medial forefoot, the peak pressure of all plantar regions was raised significantly. Likewise, an increasing slope resulted in the reduction of peak pressure of the heel, medial forefoot, and hallux and toes. The study recommends young females to pay attention to choose a suitable gradient and treadmill speeds.

Ho, I-J, Hou, Y-Y, Yang, C-H, Wu, W-L, Chen. S-K. and L-Y Guo: Comparison of plantar pressure distribution between different speed and incline during treadmill jogging.
Journal of Sports Science and Medicine (2010) 9, 154-160

The Midfoot Index of Load as an Important Parameter in the Diagnosis of Ankle Arthrodesis

Friggs et al have evaluated the usefulness of pedographic parameters in distinguishing patients with ankle or tibiotalocalcaneal (TTC) arthrodesis from healthy volunteers. A total of 134 individuals (35 healthy subjects and 99 subjects with either arthrodesis) were assessed by American Orthopaedic Foot and Ankle Society (AOFAS) scores and dynamic pedobarography (novel emed m/E). The arthrodesis patients were further investigated with radiographs.

The team of researchers has found that the interpretation of a large number of pedobarographic parameters can be reduced to the interpretation of the midfoot index of load and the evaluation of the force/pressure time graphs (i.e. to 4 parameters in total). These findings help to build a simplified diagnostic tool to distinguish between healthy volunteers and patients after ankle or TTC arthrodesis.

Frigg, A.; J. Schäfer; H. Dougall; R. Rosenthal and V. Valderrabano: The midfoot load shows impaired function after ankle arthrodesis.
Clinical Biomechanics
27 (2012): 1064–1071

The Effects of a Foot/Ankle Strengthening Programme on Sprint Performance and Plantar Loading

Using novel pedar technology, Fourchet et al. have tested the effects of a brief foot/ankle strength training program on sprint performance and on related plantar loading characteristics in young athletes. The study involved two groups of adolescent male athletes (8 subjects each). Group one underwent a foot medial arch and extrinsic ankle muscles reinforcement programme, whereas group two maintained a normal training routine. Whilst showing no differences in sprinting performance, the test results indicated significant changes in force and pressure from heel to forefoot between the two groups. '

Amongst others, the athletes undergoing special training revealed an increase in mean pressure and force in the lateral heal area. These findings will be of interest for developing preventive measures for at-risk groups such as subjects with high navicular drop or overpronators.

Fourchet. F., S. Kuitunen, O. Girard, A.J. Beard and G.P. Millet: Effects of combined foot/ankle electromyostimulation and resistance training on the in-shoe plantar pressure patterns during sprint in young athletes.
Journal of Sports Science and Medicine (2011) 10: 292-300

Jogging vs. Running - Comparison of Plantar Pressure Distribution

Fourchet et al. have compared plantar pressure distribution while jogging and running in highly-trained adolescent runners. Using novel’s X-Pedar Mobile System, 11 participants performed two constant velocity running trials on a treadmill. The test results showed an increase in relative load under the medial and central forefoot regions while jogging, while the relative load under the lesser toes was reduced. In order to prevent overloading of the metatarsal in adolescent runners, the researchers recommend avoiding excessive mileage at jogging pace.

Fourchet F., L. Kelly, C. Horobeanu, H. Loepelt, R. Taiar, G. Millet. Comparison of plantar pressure distribution in adolescent runners at low vs. high running  velocity.
Gait & Posture 35 (2012): 685–687

Tennis Courts and Plantar Pressure Loading

Studying in-shoe loading patterns during tennis activities, Girard et al have found that different playing surfaces significantly affect plantar loading. Comparing clay and Greenset playing surfaces, tests with novel pedar technology have shown that the potential danger for overloading is higher on the midfoot when playing on clay, whereas on Greenset surfaces overloading is more likely to affect the hallux and lesser toes areas. These findings are important for designing strategies against overuse injuries

Girard O., F. Eicher, F. Fourchet, J.P. Micallef, G.P. Millet: Effects of the playing surface on plantar pressures and potential injuries in tennis.
British Journal of Sports Medicine
41 (2007): 733–738